This document provides information on dengue fever. It discusses the dengue virus, which is a flavivirus transmitted by Aedes aegypti mosquitoes. It outlines the clinical presentation of dengue fever and dengue hemorrhagic fever. It also discusses pathogenesis, diagnosis, management including fluid therapy, and prevention through vector control measures targeting the Aedes mosquito. The distribution of dengue is global in tropical and subtropical regions. India has a major burden of dengue disease.

2. Alternative Names
• Onyong- Nyang Fever
• Break Bone Fever
• Dengue like Disease

3. Dengue fever
• Etiology
• Epidemiology
• Pathogenesis
• Clinical presentation
• Management
• Prevention and control

4. The Dengue Virus
• Flavivirus
• Positive sense
• Single stranded RNA virus
• 40 to 50 nanometers
• Four sero-sub types
• Type 1 to 4
• Arthropod borne

5. Dengue Virus
Electron Microscope

6. Dengue Virus
Cell Culture
Of Dengue
Virus

7. The Vector
Aedes aegypti
(Infected Female Mosquito)
(rarely Aedes albapticus)

8. Aedes aegypti
Dengue,river raft
fever YF, CGF

9. Peculiarities of A.aegypti
• It is a day biting mosquito when normally
coils, repellents, nets etc are not used
• It breads in fresh water around homes
• Lays eggs preferentially in water jars, discar-
ded containers, coconut shells, old tires etc.
• Can transmit trans-ovarially the infection
• Year round breeding 250 N to 250 S
• Tropics and sub-tropics are its favorite zones.
It is an urban vector

10. Distribution
 Endemic in more than 100 tropical and subtropical countries
 Pandemic began in South East Asia after WW II with
subsequent global spread
 Several epidemics since 1980s
 Distribution is comparable to malaria

11. Dengue - SEAR

12. Dengue - SEAR

13. Dengue - SEAR

14. Distribution

15. Epidemiology
In India first outbreak of dengue was recorded in
1812
A double peak hemorrhagic fever epidemic
occurred in India for the first time in Calcutta
between July 1963 & March 1964
In New Delhi, outbreaks of dengue fever reported
in 1967,1970,1982, &1996 n many more

16. Burden of disease in S.E. Asia
CATEGORY-A
(INDONESIA,MYANMAR & THAILAND)
CATEGORY-B
(INDIA,BANGALADESH,MALDIVES & SRILANKA)
CATEGORY-C
(BHUTAN, NEPAL)
CATEGORY-D
(DPR KOREA)

17. Dengue Endemic Areas
(almost all States/Uts except Lakshdweep)
Risk factors:
• Unplanned
urbanization
• Construction
activities
• Substandard
housing
• Water storage
practice
• Population
movement
• Heavy rainfall
• Vector abundance

18. Pathogenesis
Dengue Infection
Infected monocytes
Vasoactive mediators
Increased vascular permeability
Plasma leaking & hemoconcentration

19. Pathogenesis
Bone marrow supression
Leucopenia
Thrombocytopenia
Neutropenia

20. Causes of hemorrhagic
manifestation
• Vascular instability
• Decreased vascular integrity
• Assault on macro vasculature
• Decreased platelet function
• Increased vascular permeability
• Vascular disruption and local bleeds

21. Spectrum of clinical Presentations
• Undifferentiated fever
• Dengue Fever (DF) with the Fever- Myalgia
(FM) presentation (classical)
• Dengue Hemorrhagic Fever (DHF)
• Dengue Shock Syndrome (DSS)

22. Undifferentiated fever
• First infection with dengue virus presents with
undifferentiated viral illness.
• Maculopapular rash during the fever or during
defervescence
• Nausea vomiting and myalgia

23. Dengue fever
• IP of 2 – 7 days
• Sudden onset of fever, chills, headache
• Anorexia. Nausea, vomiting
• Back pain with severe myalgia, arthralgia
• Retro-orbital pain – break bone fever
• Macular rash – in axillary area
• Maculo - papular rash on trunk – extremities
• Leucopenia

24. Dengue Hemorrhagic fever
1. Fever or history of acute fever lasting 2-7 day
occasionally biphasic
2. Hemorrhagic tendencies evidenced by at least
one of the following :
~Positive torniquet test
~Petichiae ,ecchymosis, purpura
~Bleeding from mucosa and GIT
~Hematemesis maleana
~Thrombocytopenia

25. Dengue Hemorrhagic fever
3 . Thrombocytopenia < 100000/mm3
4 . Plasma leakage evidenced by atleast one
~Rise in hematocrit > 20 %
~ Fall in hematocrit > 20% after IV fluids
~Plural effusion,acites,hypoalbunemia

26. Dengue shock syndrome
• All four DHF Criteria plus
• Signs of circulatory failure as:
> Rapid and weak pulse
> Narrow pulse pressure { < 20 mmHg }
> Hypotension
> Cold clammy skin , restlessness

27. Earlier WHO classification

29. Four Grades of DHF/DSS
• Grade 1
Fever, Const. Symptoms, +ve tourniquet test
• Grade 2
Grade 1 + Spontaneous bleeding
• Grade 3
Signs of circulatory failure
• Grade 4
Profound shock - B.P. Pulse not recordable

30. Petechiae

31. Ecchymosis – Periorbital Edema

32. Large Subcutaneous Bleed

33. Capillary Damage

34. DHF- Poor Prognostic Signs
• Girl children under 12 with DHF/DSS
• Severe hypotension and shock
• Multifocal bleeding – abdominal pain
• CNS encephalopathy ,fits ,coma
• Watch for preorbital edema, proteinuria
postural or otherwise hypotension
• Serotype 2 infection after type 4
• Malnutrition is PROTECTIVE

35. Laboratory Diagnosis
• Complete Blood Counts
• Hematocrit
• Platelet Count
• SGOT, SGPT
• Serum Albumin
• Urine for Protein , hematuria
• Immunological Tests
• Chest X ray

36. Laboratory Diagnosis
• Leucopenia. Thrombocytopenia
• Increased SGOT, SGPT
• Rising Ab titre in paired sera
• NS1 detection ELISA(<3days)
• IgM -capture ELISA within(3-5 days)
• IgG ELISA significant of past infection
• Reverse transcription PCR confirmatory

37. Management
• Group A – patient who may be sent home.
• Group B – patient who needs in hospital
management.
• Group C – Patients who need emergency
treatment and Intensive care.

38. Management

39. Group A
• Ambulatory patients - Able to tolerate fluids
• Adequate urine output
• No warning signs
• Rx
• Reviewed daily for disease progression { warning signs
hct and leucopenia }
• Plenty of oral fluids
• Antipyretics {aspirin, ibuprofen NSAIDS should be
avoided – gastritis and bleeding}
• Immediate consultation for severe abdominal pain
vomitings cold clamy limbs black stools and oligourea

40. Group B
• Patients with warning signs or those
with co-existing that may make
dengue or its management more
complicated (infancy, dual infection,
or congenital anomalies)

41. Group B
• Rx
• Obtain baseline hematocrit before IV fluids
• Start with 5-7 ml/kg for 1-2 hours
• Reduce to 3-5 ml/kg for 2-4 hours
• Reduce to 2-3 ml/kg/hr as per clinical
response and urine output .
• Isotonic solutions should be preferred.

42. Group C
• Pt who require emergency treatment and
urgent referral
• Severe Plasma leakage, severe
HEMORRHAGES, severe organ impairment.

43. Treatment Of Compensated Shock

45. Treatment of hypotensive shock

47. Monitoring during T/t of shock
• Vitals { pulse oxymetry }
• ECG
• Arterial blood gas
• Sr. lactate
• Blood glucose level
• LFTs and KFT
• Coagulation profile

48. Risk of bleeding
• Patient at risk of major bleeding
• Renal & Hepatic failure & persistent metabolic
acidosis
• NSAID Therapy
• Pre existing peptic disease
• On anticoagulant therapy
• Any trauma including IM Injection

49. Treatment of hemorrhagic
complication
• No IM injections
• Strict bed rest
• Blood transfusion is life saving but should be
used cautiously
• Platelet in case of profound thrombocytopenia
and active bleeding
• Maintainace of perfusion of vital organs with
judicious use of crystalloid and colloids

50. Adjuvant Therapy
• Vasopressor and inotrops ( fluid refrac..)
• Renal replacement therapy in ARF
• Treatment of complication like LIVER FAILURE
and ENCEPHALOPATHY

51. Is there any role of Platelets ????
• NO….
• Indicated only in Pt with active BLEED or
PROFOUND THROMBOCYTOPENIA (<10,000)

52. Is there role of STEROID??????
• NO….

53. Choice Of Iv Fluids
• Crystalloids – NORMAL SALINE(300), RINGER
LACTATE(273)
• NS – is ideal for initial ressucitation but if
continued there is a risk of hyperchloremic
acidosis
• RL – its may be not sutaible for initial ressuci..
But is continued as a maintainance fluid.
Contraindicated in liver failure..

54. India

55. Vector Control of Dengue
BiCEPs

56. Vector Control of Dengue
Aedes Control Methods
• Biological methods (e.g. fish, Copepods – small crustaceans that feed on
mosquito larvae) to kill or reduce larval mosquito populations in water
containers.
• Chemical methods
 against the mosquito’s aquatic stages for use in larger water containers
(e.g. Temephos).
 against adult mosquitoes, such as insecticide space sprays.
• Environmental sanitation measures to reduce mosquito breeding sites, such as
physical management of water containers (e.g. mosquito-proof covers for wate
storage containers,polystyrene beads in water tanks), better designed and
reliable water supplies, and recycling of solid waste such as discarded tyres,
bottles, and cans.
• Personal protection through use of repellents, vaporizers, mosquito
coils, and insecticide treated screens, curtains, and bednets (for daytime
use against Aedes).

57. Vector Control of Dengue
Aedes Control Methods
• Challenges
1. fogging :
 costly and its effectiveness is limited.
 Ae. aegypti prefers to rest insidehouses, so truck mounted
or aerial insecticide spraying simply does not reach
mosquitoes resting in hidden places such as cupboards.
 Home-owners in various places may refuse entry to spray
teams for indoor space spraying, or shut windows and
doors to prevent outdoor insecticidal fogs from entering
their house
2. Larval control:eggs can remain dormant for more than a
year in dry condition,transovarian transmission

58. NVBDCP- Dengue
Mid Term Plan ( ‘Octalogue’) :
• Surveillance - Disease and Entomological Surveillance
• Case Management - Laboratory diagnosis and Clinical Management
• Vector Management - Environmental management for Source Reduction,
Chemical control, Personal protection and Legislation
• Outbreak response - Epidemic preparedness and Media Management
• Capacity building- Training, strengthening human resource and
operational research
• Behaviour Change Communication - Social mobilization and information
Education and Communication (IEC)
• Inter-sectoral coordination – with Ministries of Urban Development, Rural
Development, Panchayati Raj, Surface Transport and Education sector
• Monitoring and Supervision - Analysis of reports, review, field visit and
feedback

59. NVBDCP- Dengue
• Surveillance - Disease and Entomological
Surveillance
Entomological indictors for dengue vector :
• House index : % Houses & their premises positive for
Immatures (More than 10 % High less than 1% Low Risk).
• Container Index : % Water Holding Containers positive for
Imatures
• Breteau Index : No. of Positive containers per 100 houses
(100 houses ideal; More than 50% High Risk; Less than 5%
Low Risk).

60. NVBDCP- Dengue
• Case Management - Laboratory diagnosis and
Clinical Management
• For early diagnosis ELISA based NS1 kits have
been introduced under the programme which
can detect the cases from 1st day of infection.
IgM capture ELISA tests can detect the cases
after 5th day of infection.

61. NVBDCP- Dengue
Behaviour Change Communication
• Anti Dengue Month-July
• 16TH May--- National
Dengue Day
• Mobile app
Effective community participation

62. NVBDCP- Urban VBD Scheme
• Urban Malaria constitutes about 10% of the total malaria in
the country
• Earlier known as Urban Malaria Scheme
• presently functional in 132 towns in the country.
• as other vector borne disease namely Dengue, Chikungunya,
Filaria and Japanese encephalitis are also being reported in
these towns and to be tackled in terms of disease and vector
management.

63. NVBDCP- Urban VBD Scheme

64. Advances
1. Immunization: e ach serotype produces life
long immunity. Vaccine needs to be tetravalent.
• A live-attenuated tetravalent vaccine based on
chimeric yellow fever-dengue virus (CYD-TDV),
has progressed to phase III efficacy studies.
2.Upcoming trial: Australian experts to manipulate
mosquitoes. The methodology uses ‘wolbachia’, a
bacterium that kills the aedes aegypti’s ability to
spread the disease
(Sanofi Pasteur)

65. Thank You